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a <br /> SAN JOAQUIN CVJNTY PUBLIU HEALTH SERVICES. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> / P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> AppllCation is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. , I <br /> City <br /> O t�Lot Size/Acreage <br /> Jab Address / <br /> 6. C L^F'hone <br /> Owner's Name w Address iT?Z,��7_� <br /> Contractor jgs�:rl"_ <br /> G. Address -X2 - ,�'°" P License tyo Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ <br /> OTHER p Monitoring Well - <br /> DISTANCE 7O NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS .I <br /> USE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED - Dia. of Wel! Casing <br /> h C'1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation ry <br /> Type of-Casing_ ""'Specifications <br /> ?(Domestic/Private O'Gravel Pack. - -.❑-Tracy Type.of Grout (1 <br /> 1'i Public Cl Other f-1 Delta Depth of Grout Seal v ACV• <br /> I i Irrigation —.Approx. 0th I I Eastern Surface.Seal Installed by O <br /> H.P. State Work Done <br /> Repair Work Done 75 Type of Pump- Sealing Material & Depth <br /> Well Destruction C3Well Diameter Filler Material & Depth .. <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.) REPAIR/ADDITION I I DESTRUCTION I i aNailabPelw Thin 200 feetsystem �lpd it public'spwer is h 1 <br /> Installation will serve: Residence— Commercial — Other 1 <br /> Number of living units:-_ .__ Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: ' <br /> SEPTIC TANK. ❑ Type/Mfgj - Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> "'Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE.. Cl. No. A Length of.lines Total length/size c <br /> FILTER BED C] Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size — Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> } DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and , <br /> rules and regulations of the San Joaquin County <br /> ' Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shah not <br /> employ any person in such manner as to become subject'to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> l certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's c mpensa- <br /> ffff tion Iowa of Califo <br /> I <br /> The appfic must ca for all required ins tions. Complete drawing an ev aside. <br /> Signed _ <br /> Title: Date: <br /> OR DEPARTMENT USE ONLY <br /> 4 Date Area 0 <br /> Application Accepted by <br /> Pit or Grout Inspection by Date <br /> Final Inspection by ` Date <br /> Additional Comments: <br /> r Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, p O Box 2009, Stkn, GA 85201 <br /> FEECK RECEIVED BY 0 E PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> . EH 13-24(REV. 51 r� • �' <br /> 4 EH 14.2E <br />